Makindo Medical Notes.com

Related Subjects: |Hypoadrenalism |Cushing Disease |Cushing Syndrome |ACTH (Adrenocorticotropic hormone) |Acromegaly and Giantism | Pituitary Adenoma | Pituitary Apoplexy |Diabetes Insipidus (Cranial and Nephrogenic)

A pituitary tumour either haemorrhages or infarcts. Seen especially with larger macroadenomas

About

• Pituitary tumour either outgrows its blood supply or is compromised by a fall in blood pressure

Causes

• Existing Pituitary Adenoma: pre-existing pituitary tumour, especially macroadenomas.
• Anticoagulation Therapy: increase the risk of haemorrhage within the pituitary gland.
• Major Surgery or Trauma: Physical stress or trauma can precipitate apoplexy.
• Pregnancy: Hormonal changes during pregnancy, raising the risk of apoplexy.
• Hypertension: High blood pressure
• Radiation Therapy: Radiation treatment
• Other Triggers: dynamic pituitary function testing, pituitary stimulation, and infections.

Clinical

• Collapsed, Coma, Delirium, Reduced LOC
• Pre-existing symptoms of a macroadenoma e.g. Cushing's disease
• Macroadenoma may be secretory or non-secretory
• Sudden severe thunderclap headache, coma, visual loss
• Hypotensive shocked with secondary hypoadrenalism
• Ophthalmoplegia, bitemporal hemianopia, subarachnoid haemorrhage

Investigations

• Blood: FBC, U&E, LFT, Clotting profile
• MRI: The imaging modality of choice. See haemorrhage or infarction in the pituitary gland
• CT Scan: useful acutely but less sensitive than MRI for detecting pituitary abnormalities.
• Endocrine Testing: Serum cortisol, ACTH, TFTs,PRL to assess pituitary function.
• Visual Field Testing: To evaluate the extent of visual loss or field defects.

Management

• Hormone replacement Hydrocortisone 100-200 mg IV stat and then 6 hourly to manage acute period by IM route.
• Urgent neurosurgical referral and transsphenoidal surgery. Pituitary hormone replacement
• Close endocrinology and neurosurgical cooperation
• Post operative assessment and monitoring of pituitary function and oral Hydrocortisone if needed

Prognosis

• Depends on the severity of the initial event, the speed of diagnosis, and the promptness of treatment:
• Visual Recovery: Early surgical decompression improves the chances of visual recovery
• Endocrine Function: may have permanent hypopituitarism, requiring lifelong hormone replacement therapy.

Reference

• UK Guidelines for the Management of Pituitary Apoplexy